Prior authorization is required for the providers to determine claim coverage and for approval or authorization from an insurance carrier to pay for a proposed treatment or service. This approval is based on medical necessity, medical appropriateness and benefit limits. For example, if an ordering physician has to obtain pre-authorization from an insurance company for the use of a particular drug, the physician must send a pre-authorization request so that the insurer can determine whether the drug is medically appropriate and safe to use before agreeing to pay.

Prior Authorization requirements:

  • A requirement for prior authorization.
  • Drugs that are not preventive, or used to treat non-life threatening patients.
  • Drugs that are not covered by your insurance but deemed medically necessary by your provider.
  • Drugs with adverse health effects.
  • Drugs that are intended for certain age groups.
  • Brand name drugs prescribed when a generic is available.
  • In many cases, prior authorizations are intended to be a control to ensure drug use is appropriate and the most clinical and cost-effective therapy is being used.